a blog of books every doctor should read

The Patient’s Guide to Preventing Medical Errors

BOOK CONTENTS

Patient safety is a top priority for medicine and there are a variety of resources available to healthcare workers on how to prevent medical errors. There are however very few books written for patients to protect themselves from healthcare-related harm. The author ‘found a myriad of information on reducing medical errors designed for professionals, but very little targeted for the consumer’ (page xiii). In redressing this problem she has written a comprehensive book which explores every aspect of patient safety. She set out to encourage patients ‘…to be more involved in their healthcare’ (page ix) and to empower them to ‘…feel more confident and less intimidated in speaking up about their concerns’ (page xiv).

The book reviewed the high frequency of healthcare-related patient harm. The author referred in several places to the groundbreaking Institute of Medicine report, ‘To Err is Human’, which established the great degree to which patients were harmed in healthcare institutions; the author likened this to the risk of mountain climbing or bungee jumping (page xi). She however emphasised that this harm is often not the outcome of deliberate or careless acts; ‘…with no malicious intent, some hospitals have harmed rather than healed people‘ (page ix).

The author comprehensively discussed the causes of medical error. She explained the Swiss cheese model of error causation (page 12), and reviewed how system factors trigger ‘the cascade of failures‘ that result in harm (page 105). She explored human factors such as fatigue, communication, teamwork, and the ‘culture of low expectations’ (page 28). She referred to the challenges of increasing medical knowledge and rising complexity of technology (page 92). The book reviewed safety data collection and management (page 77), patient safety monitoring (page 65) and major events investigation (page 67). She also gave an overview of physician accreditation, monitoring and sanctioning (page 57). Other topics the book covered include disclosure, incident reporting systems, near misses, mediation, arbitration, litigation, and health safety legislation (page 47).

The author, a nurse, uses many heart-wrenching stories to illustrate the genesis and impact of medical error. The story of 17-year-old Jessica Santillan for example showed how blood group incompatibility fatally complicated a routine heart-lung transplantation at Duke Hospital (page 1). Another example is the widely publicised story of health reporter Betsy Lehman who died of an overdose of breast cancer chemotherapy at the famous Dana-Farber Cancer Institute (page 41). The book demonstrated the malign influence of system factors on patient safety with the anecdote of Miguel Sanchez who died from a prescription error. In Miguel’s case ‘…more than 50 system failures led to this devastating error’ (page 105). Other stories illustrated the broad range of possible harm that may arise such as restrain injuries (page 22), allergic reactions (page 46), and anaesthetic complications (page 97).

By DiverDave (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)%5D, via Wikimedia CommonsThe author dispensed numerous helpful tips throughout the book to aid patients prevent harm whenever they engage healthcare. This follows from her tenet that ‘when you are receiving health care services, you can be the most important factor in preventing an error from affecting you’ (page 6). These tips covered every conceivable situation where error might occur. Take for example her advice to ‘speak up immediately if something seems questionable’ (page 10) and ‘never assume that your doctor and other health care workers have communicated important facts about your care to each other’ (page 13). Some of the suggestions are directed at healthcare practitioners for example the suggestion that ‘when patients question the clinician, they should be heard and their ideas incorporated into care’ (page 39). Her last chapter, ‘what you can do to protect yourself‘, is a must-read for anyone coming into contact with healthcare establishments.

OPINION

This is a comprehensive and well-researched book, and the writing is clear and passionate. It addresses almost every aspect of patient safety and contains many illustrative anecdotes. The book covered the spectrum of medical care and offers invaluable advice to guide both patients and healthcare providers. It could do with a more attractive cover and shorter anecdotes but there is very little else to criticise about this excellent book.

OVERALL ASSESSMENT

This book is written for the general public but it has very useful information for doctors and other healthcare practitioners. The author encourages patients to be involved in their care and to challenge their caregivers when their safety is threatened. The book encourages a collaborative approach to patient safety and shows how this equally benefits patients and healthcare providers. It is an outstanding book, valuable for healthcare, and I highly recommend it for doctors.